Midterm Exam Study Guide for RNSG 1125
Clinical Judgment
- Definition: Interpretation or conclusion about a patient’s needs, concerns, or health problems, and the decision to take action, modify standard approaches or improvise new ones based on the patient’s response.
- Antecedents:
- Sound judgment skills
- Analytical reasoning skills
- Awareness of patient & self
- Creativity/inquisitiveness
- Sound knowledge base
- Persistence
- Attributes:
- Appropriate response
- Holistic view of patient and situation
- Process orientation
- Reasoning and interpretation
- Positive Consequences:
- Improved patient outcomes
- Evidence-based nursing care
- Enhanced patient education and nurse-patient relationship
- Negative Consequences:
- Unsafe nursing care
- Failure to rescue patients
- Breach of professional boundaries
- Ineffective communication with patients/families
- Breakdowns in decision-making process
Tanner’s Clinical Judgment Model
- Noticing: Perception of the situation, influenced by context, experience, knowledge, ethical perspective, and nurse-patient relationship.
- Interpreting: Attributing meaning to data through various reasoning methods.
- Diagnosing/Analyzing component
- Responding: Deciding on action and monitoring outcomes.
- Implementing/Intervention component
- Reflecting:
- In-action: Continuous assessment during care.
- On-action: Reflective practice after care to evaluate outcomes.
Subjective vs Objective Data
- Subjective Data: Subject to change, based on what the patient describes.
- Objective Data: Observable and measurable data collected by the nurse.
Clinical Judgment Measurement Model
- Models 6 cognitive operations following Tanner's model:
- Recognizing cues
- Analyzing cues
- Prioritizing hypotheses
- Generating solutions
- Taking action
- Evaluating outcomes
Nursing Process
- Definition: Organized thinking to navigate complex situations; guides assessments and behaviors.
- AD PIE:
- Assessment
- Diagnosing/Identifying Problems
- Planning
- Identifying Interventions
- Evaluation
- Parts of Nursing Diagnosis: Problem, etiology (related to), symptoms (as evidenced by).
- Planning: Set patient-centered, measurable, and prioritized goals (considering Maslow's hierarchy).
- Implementation: Carrying out interventions.
- Evaluation: Reevaluating the problem to see if goals were met.
Clinical Decision Making Models
- Humanistic Intuitive Approach: Relying on experience for dynamic decision-making.
- Information Processing Model: Mirrors human thought processes akin to computer processing.
- Cognitive Continuum Theory: Merges intuitive and analytical cognitive characteristics.
- REST Framework: Involves moral reasoning processes that guide ethical judgment.
Critical Thinking in Nursing
- Developable skill requiring situational awareness.
- Levels:
- Basic: Trust in experts, based on rules.
- Complex: Expressing autonomy, analyzing problems.
Medication Orders
- 7 Rights: Right route, time, drug, patient, dose, documentation, education.
Evidence Based Practice (EBP)
- Definition: Integrates best current evidence with clinical expertise and patient/family preferences for optimal care.
- Antecedents:
- Problem identification
- Recognition of research's nursing significance
- Attributes:
- Replicability, reliability, validity
- Individualized care
Nightingale’s Influence
- Set standards for nursing skills and education.
- Introduced sanitation practices, reducing infection rates.
Research in Nursing
- Scientific Inquiry: Systematic data collection to develop theories and solutions.
- Types of Research:
- Quantitative: Involves measurable data, randomized controlled trials.
- Qualitative: Explores patient experiences and perceptions using non-numeric data.
- PICO(T) Questions: Framework for clinical inquiries.
Professionalism in Nursing
- Definition: Integration of nursing skills with dignity and respect for all individuals.
- Attributes: Competence, accountability, lifelong learning, advocacy.
- Aims: Promoting health, preventing illness, restoring health, facilitating coping with disabilities.
- Healthy People 2030 Guidelines: Strategies to eliminate health disparities and promote well-being.
- Preventing Illness: Education programs to guide healthy behaviors.
- Professional organizations promote standards and advocacy in nursing.
- DECS: Differentiated essential competencies for nursing.
- Nursing Hierarchy: Defines roles and delegation in practice.
Safety in Nursing
- Definition: Protection from harm through effective practices.
- Attributes: Emphasis on injury-free care.
- Prevention of Medication Errors: Use of two patient identifiers and barcoding techniques.
Conclusion
- Emphasize the significance of clinical judgment, evidence-based practice, critical thinking, and professional integrity as central to nursing excellence.